Event Notification Report for August 31, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/30/2004 - 08/31/2004
Power Reactor
Event Number: 41002
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: DANIEL MALONE
HQ OPS Officer: BILL GOTT
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: DANIEL MALONE
HQ OPS Officer: BILL GOTT
Notification Date: 08/31/2004
Notification Time: 09:38 [ET]
Event Date: 08/31/2004
Event Time: 07:18 [EDT]
Last Update Date: 08/31/2004
Notification Time: 09:38 [ET]
Event Date: 08/31/2004
Event Time: 07:18 [EDT]
Last Update Date: 08/31/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JULIO LARA (R3)
RICHARD WESSMAN (IRD)
TERRY REIS (NRR)
MICHAEL CASE (NRR)
JULIO LARA (R3)
RICHARD WESSMAN (IRD)
TERRY REIS (NRR)
MICHAEL CASE (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 95 | Power Operation | 0 | Hot Standby |
RPS ACTUATION DUE TO FIRE IN 2B CONDENSATE PUMP
"At 0718 EDT, the reactor was manually tripped from approximately 95% power following notification to the control room of a fire associated with condensate pump 2B. Initially, upon notification of smoke at the condensate pump, a rapid down power had been commenced, wherein reactor power was reduced from 100% to approximately 95% power.
"An automatic actuation of the auxiliary feedwater system also occurred as designed to maintain steam generator water level following the reactor trip.
"The fire was extinguished in less than 10 minutes. The local fire department was notified, responded to the site as a precautionary measure, but was not used in extinguishing the fire. All systems functioned as designed. The reactor is stable in mode 3."
Decay heat is being removed with the steam generators discharging steam to the main condenser.
The licensee notified the NRC Resident Inspector.
"At 0718 EDT, the reactor was manually tripped from approximately 95% power following notification to the control room of a fire associated with condensate pump 2B. Initially, upon notification of smoke at the condensate pump, a rapid down power had been commenced, wherein reactor power was reduced from 100% to approximately 95% power.
"An automatic actuation of the auxiliary feedwater system also occurred as designed to maintain steam generator water level following the reactor trip.
"The fire was extinguished in less than 10 minutes. The local fire department was notified, responded to the site as a precautionary measure, but was not used in extinguishing the fire. All systems functioned as designed. The reactor is stable in mode 3."
Decay heat is being removed with the steam generators discharging steam to the main condenser.
The licensee notified the NRC Resident Inspector.
General Information or Other
Event Number: 41008
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: AURORA State: WI
County:
License #: 09-1017-01
Agreement: Y
Docket:
NRC Notified By: PAUL CALEB
HQ OPS Officer: JOHN MacKINNON
Licensee: AURORA BAYCARE MEDICAL CENTER
Region: 3
City: AURORA State: WI
County:
License #: 09-1017-01
Agreement: Y
Docket:
NRC Notified By: PAUL CALEB
HQ OPS Officer: JOHN MacKINNON
Notification Date: 09/02/2004
Notification Time: 11:20 [ET]
Event Date: 08/31/2004
Event Time: 14:00 [CDT]
Last Update Date: 09/02/2004
Notification Time: 11:20 [ET]
Event Date: 08/31/2004
Event Time: 14:00 [CDT]
Last Update Date: 09/02/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JULIO LARA (R3)
LINDA GERSEY (NMSS)
JULIO LARA (R3)
LINDA GERSEY (NMSS)
WISCONSIN AGREEMENT STATE REPORT: SOURCE FAILED TO RETRACT
"On the evening of August 31, 2004 during a mammosite treatment utilizing a Varian HDR unit, the source failed to retract upon completion of the treatment time. The licensee's RSO/AMP had to enter the treatment room and retract the source manually.
"The licensee subsequently contacted Varian for assistance. A service representative from Varian arrived at Aurora Baycare Medical Center on Wednesday, Sept. 1, 2004. The Varian service representative found nothing wrong with the HDR unit. However, approximately 2 cm of the connecting catheter had 'buckled' (appeared melted and twisted), possibly restricting source movement. The licensee has contacted the catheter manufacturer for assistance in analyzing the catheter to determine what may have caused it to buckle.
"Preliminary dose indications by the licensee indicate that the patient received an additional amount of dose to the skin while the source was being retracted. The licensee reported that the most probable estimate of the additional skin dose is 1.0 Gy."
"On the evening of August 31, 2004 during a mammosite treatment utilizing a Varian HDR unit, the source failed to retract upon completion of the treatment time. The licensee's RSO/AMP had to enter the treatment room and retract the source manually.
"The licensee subsequently contacted Varian for assistance. A service representative from Varian arrived at Aurora Baycare Medical Center on Wednesday, Sept. 1, 2004. The Varian service representative found nothing wrong with the HDR unit. However, approximately 2 cm of the connecting catheter had 'buckled' (appeared melted and twisted), possibly restricting source movement. The licensee has contacted the catheter manufacturer for assistance in analyzing the catheter to determine what may have caused it to buckle.
"Preliminary dose indications by the licensee indicate that the patient received an additional amount of dose to the skin while the source was being retracted. The licensee reported that the most probable estimate of the additional skin dose is 1.0 Gy."
Hospital
Event Number: 41143
Rep Org: MASSACHUSETTS RADIATION CONTROL
Licensee: LAHEY CLINIC FOUNDATION
Region: 1
City: BURLINGTON State: MA
County:
License #: 44-0015
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL HUFFMAN
Licensee: LAHEY CLINIC FOUNDATION
Region: 1
City: BURLINGTON State: MA
County:
License #: 44-0015
Agreement: Y
Docket:
NRC Notified By: MIKE WHALEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/22/2004
Notification Time: 15:26 [ET]
Event Date: 08/31/2004
Event Time: 00:00 [EDT]
Last Update Date: 10/22/2004
Notification Time: 15:26 [ET]
Event Date: 08/31/2004
Event Time: 00:00 [EDT]
Last Update Date: 10/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RONALD BELLAMY (R1)
SCOTT MOORE (NMSS)
RONALD BELLAMY (R1)
SCOTT MOORE (NMSS)
AGREEMENT STATE REPORT OF MEDICAL MISADMINISTRATION
"Patient scheduled to receive template-guided transperineal prostate interstitial brachytherapy for clinical localized prostate cancer was to receive 72 I-125 seeds, instead received 47 seeds resulting in underexposure of greater than 20%."
"The cartridges carrying 15 seeds each were loaded into a 'Mick' applicator. Transrectal ultrasound was used for localization of the prostate and implant needles; fluoroscopy was used very little during the procedure to minimize staff exposure. As each seed was injected into the prostate, it was recorded both on paper and in computer system and final tabulation was 77 seeds were implanted. However, x-rays taken after the procedure showed only 47 seeds had been implanted, although distribution appeared satisfactory."
"Patient scheduled to receive template-guided transperineal prostate interstitial brachytherapy for clinical localized prostate cancer was to receive 72 I-125 seeds, instead received 47 seeds resulting in underexposure of greater than 20%."
"The cartridges carrying 15 seeds each were loaded into a 'Mick' applicator. Transrectal ultrasound was used for localization of the prostate and implant needles; fluoroscopy was used very little during the procedure to minimize staff exposure. As each seed was injected into the prostate, it was recorded both on paper and in computer system and final tabulation was 77 seeds were implanted. However, x-rays taken after the procedure showed only 47 seeds had been implanted, although distribution appeared satisfactory."